Progressive Necrotizing Ocular Surface Disease, Despite Immunosuppression.

A 60-year-old man was referred with 2 years of left conjunctivitis that persisted despite antibiotic and systemic corticosteroid therapy. The severity and extent of surface disease had increased slowly after prior dacryocystorhinostomy. Subsequent conjunctival biopsies demonstrated granulomas with patchy necrosis but no evidence of malignancy or organisms; systemic screening for sarcoidosis and tuberculosis was negative. A markedly thickened and inflamed left ocular surface was present on referral, with areas of conjunctival ischemia and patchy white slough on the tarsi. Further ocular surface biopsy did not reveal malignancy, and therefore mycobacterial infection was considered a possible cause. Mycobacterium tuberculosis was cultured, albeit only after repeated conjunctival swabs and biopsies. Appropriate treatment led to a very rapid resolution of ocular surface disease. Localized periocular tuberculosis is extremely rare outside developing nations, and its rarity may cause this differential diagnosis for persistent severe ocular surface disease to be overlooked in industrialized nations.